Australia has had significant successes in reducing the prevalence of and harm from tobacco use. Far fewer Australians are smoking and being exposed to secondhand smoke as a result of comprehensive public health approaches. The daily smoking rate among smokers aged 14 years and over has almost halved from 30.5% in 1988 to 15.9% in 2010.1
However many smokers continue to smoke despite a strong regret that they ever started2 and numerous attempts to quit.3 Smoking rates continue to be unacceptably high, particularly among Aboriginal and Torres Strait Islander people, of whom about 45% smoked daily in 2008.4 (Refer to Chapter 8, Section 8.3.) Smoking rates among those with mental health problems and those in prison are also substantially higher than those in the general population. (See Chapter 1, Section 1.10.)
The prevalence of smoking is expected to continue to decline in Australia in response to the declining social acceptability of smoking and the effects of longstanding and strengthened policies that outlaw the promotion of tobacco products, increase knowledge of health effects and prevent tobacco products from becoming more affordable. Population-wide strategies such as these not only encourage attempts to quit but also reduce prompts to relapse. In recent years governments have also increasingly invested in services and treatments demonstrated to increase the likelihood of success of a single quit attempt. The need to institutionalise such efforts in Australia's healthcare system has been set out in several important policy documents since 2004.
The National Tobacco Strategy 2004–20095 made the case for an integrated national strategy for improving the quality of, and access to, services and treatment for smokers as part of a comprehensive approach to reducing tobacco-related harm.
'A comprehensive national plan for treating tobacco dependence would enable coordination of policy and spending by programs covering public health, medical and pharmaceutical benefits, medical education, the development of general practice and continuing education of virtually all health professionals.
Ideally, telephone call-back and internet services would be available to smokers from any part of the country and the benefits of Quitlines and other services would be vigorously promoted. Every smoker would be able to afford a clinically appropriate pharmacotherapy, and such treatments would be subsidised where the patient was also undertaking a behavioural support program. In all health care settings, general practitioners, community pharmacists, practice nurses, hospital nurses, specialists, dentists and other health professionals would be trained and supported to identify, encourage and support smokers to quit. GPs and other health professionals in all parts of the country would be able to refer patients to the Quitline. Identification and treatment of smokers would be national performance indicator for Australian hospitals.'5
A detailed paper outlining ideas and resources to advance this goal was published along with the strategy.6
Since 2004, governments in Australia have increased funding for quitlines and the services offered by quitlines have expanded considerably in most states to include encouragement to remain quit provided by callback services, internet-based programs and contacts by text messaging. The National Tobacco Strategy 2004–2009 has been evaluated. Following consideration of the findings of the evaluation, a new National Tobacco Strategy is being developed.
Several other international and national documents are relevant to national policy related to smoking cessation. They include strategies to encourage and assist tobacco cessation as a key component of tobacco control.
Australia is a full Party to the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Australia is thus legally bound to perform, in good faith, the full range of obligations set out in this treaty. Progress in tobacco control in Australia is now intimately connected with FCTC processes.
For the first time ever a global policy exists, set by a United Nations treaty, to support countries in developing treatment systems to help those addicted to tobacco to become tobacco free. One of the suggested implications for the future is that the guidelines challenge scientists and policy advocates to renew efforts to work with governments to develop and monitor effective tobacco dependence treatments systems.7
In November 2010, the fourth Conference of the Parties (COP4) to the WHO FCTC adopted guidelines for the implementation of Article 14 (tobacco cessation and treatment) of the convention. Article 14 asks Parties to develop national guidelines and effective measures to encourage and assist tobacco cessation.8
Few countries internationally have well-developed tobacco dependence treatment services and treatment for tobacco dependence is not yet a priority in most countries.7
The aim of the National Drug Strategy 2010–2015 is to build safe and healthy communities by minimising alcohol, tobacco and other drug-related health, social and economic harms among individuals, families and communities. With respect to tobacco control the key elements of the strategy are to:
The National Drug Strategy includes commitments to partnerships across sectors, consumer participation, building the evidence base, evidence-informed practice and innovation, monitoring performance and developing a skilled workforce that can deliver the strategy. Each of these has relevance for cessation strategies at a national level.9
The National Preventative Health Taskforce was established in April 2008 to develop the National Preventative Health Strategy, focusing initially on obesity, tobacco and excessive consumption of alcohol. The main report, Australia: the Healthiest Country by 2020,10 and the Technical Report No. 2 Tobacco Control in Australia: Making Smoking History11 set out several recommendations in relation to health system initiatives to encourage and support smoking cessation. In May 2010 the Australian Government set out its response to the taskforce report including proposed action on each of the recommendations in Taking Preventative Action–A Response to Australia: The Healthiest Country by 2020– The Report of the National Preventative Health Taskforce.12 The taskforce's recommendations concerning support and assistance to smokers and are set out below together with the Government's responses–refer pages 71 to 73.
'Key action area 6
Ensure all smokers in contact with health services are encouraged and supported to quit, with particular efforts to reach pregnant women and those with chronic health problems
6.1 Ensure all state or territory funded healthcare services (general, maternity and psychiatric) are smoke-free, protecting staff, patients and visitors from exposure to second-hand smoke both indoors and on facility grounds.
6.2 Ensure all patients are routinely asked about their smoking status and supported to quit, both while being treated and post-discharge.
6.2.1 Include requirement in hospital accreditation procedures.
6.2.2 Include a requirement in service funding agreements and performance contracts with senior staff.
6.2.3 Provide training in institutional or health-service procedures for assessment and referral.
6.2.4 Provide training in smoking cessation in pre-service training and continuing professional education for all health workers.
The Commonwealth Government strongly supports the value of brief interventions for lifestyle-related risk factors, including smoking. The Commonwealth Government will consult the Safety and Quality Commission (which will be established permanently as part of the National Health and Hospitals Network) on these actions in the context of the Commission's development of clinical safety and quality standards. The Commonwealth will raise this with the states and territories at the Australian Health Ministers' Conference. As par t of the National Smoke-Free Pregnancy Project, which received funding of $1.85 million (GST inclusive) over two years from the Commonwealth Government, midwives in 41 public hospitals were trained to conduct brief smoking cessation interventions for pregnant women and their partners at each visit.
6.3 Improve the quality and use of pharmacotherapies and services demonstrated to assist with smoking cessation.
The Commonwealth Government will task the Australian National Preventive Health Agency, in consultation with the Quitlines and other expert stakeholders, to bring together the evidence on best practice in this area and commission regular updates of best practice guidelines.
6.4 Increase availability of Quitline service.
Commonwealth Government officials will work with state and territory Quitline officials to conduct an evaluation and review of Quitline hours and services by 2012.
6.4.1 Ensure that Quitlines are resourced to respond to projected demand from media campaigns.
The Taskforce's report notes that the Quitlines are currently under-utilised. Consistent with existing practice, the Commonwealth Government will keep state and territory governments and Quitlines informed as new social marketing campaigns are rolled out so that demand on services can be monitored and resourcing can be considered if necessary.
6.4.2 Fund the development and delivery of interactive smoking cessation services using approaches such as internet, mobile phone and web-enabled mobile devices.
The Commonwealth Government will task the Australian National Preventive Health Agency to investigate options in this area.
6.4.3 Establish special Quitline counselling services for pregnant women, including call-back services and feedback to treating obstetricians/GPs/ midwives.
6.4.4 Establish a group of counsellors within one or more Quitlines who would deal specifically with people needing to use interpreter services.
6.4.5 Establish a group of counsellors within one or more Quitlines who would deal specifically with people receiving specialist treatment for chronic health conditions (asthma, diabetes, arthritis, CVD etc), mental illness, providing call-back services and feedback to treating health professionals.
Quitlines are operated by states and territories. The Government will discuss these recommendations with states and territories through the Quit Group. The Australian National Preventive Health Agency will be tasked with reporting biennially on progress in this area as part of its report on the state of preventative health in Australia. In addition, from 1 July 2010, the National Pregnancy Telephone Counselling Helpline will refer callers seeking help with smoking to Quitlines.
6.5 Ensure that NRT is affordable for all those for whom it is clinically appropriate.
6.5.1 Investigate options for provision including through the Quitline and through the PBS.
6.5.2 Ensure availability of NRT and Quitline services for patients and clients of all state and territory health services.
The Government currently provides over $60 million annually in subsidies for smoking cessation aids under the Pharmaceutical Benefits Scheme (PBS). The smoking cessation aids Bupropion (Zyban) and Varenicline (Champix) are subsidised. Nicotine patches are also available on the PBS for Indigenous Australians and on the Repatriation PBS. The Pharmaceutical Benefits Advisory Committee has recommended the listing of nicotine patches on the PBS as an aid to smoking cessation for smokers more generally. The Government will consider this recommendation in due course.i The Commonwealth will raise action 6.5.2 with the states and territories through the Australian Health Ministers' Conference.
6.6 Explore whether financial incentives might be effective in helping people to quit or stay non-smokers.
6.6.1 Consider exempting from Fringe Benefits Tax employers who cover the costs of cessation therapies or who provide financial incentives to quit.
6.6.2 Trial incentive program for young Indigenous children to stay smokefree, remain at school, etc.
6.6.3 Trial projects that use incentive payments to help people to retain their resolve to stay stopped after quitting.
The Government does not support the proposed exemption from Fringe Benefits Tax for employers who cover the costs of cessation therapies or who provide financial incentives to quit
The Government will task the Australian National Preventive Health Agency to keep the evidence on financial incentives for quitting smoking under review.'
(Australian Government, Response to the national Preventative Health Taskforce, 2010,12 pages 71 to 73)
In 2009 all governments in Australia signed an agreement articulating a shared commitment to address tobacco use, excessive use of alcohol and obesity in Australia. The National Partnership Agreement on Public Health13 extends from 1 July 2009 to 30 June 2015 and commits the Australian Government to provide $61 million over the period 2009–10 to 2012–13 in funds for social marketing to discourage smoking. It also provides $17.6 million for a National Preventive Health Agency and $13 million for a Research Fund from 2009–10 to 2012–13. Part of the brief of the agency is to advance the cessation initiatives in bold above in the Australian Government's response to the taskforce report.
i NRT was listed on the PBS in January 2011.
1. Australian Institute of Health and Welfare. Australia's health 2010. Australia's health no. 12, cat. no. AUS 122. Canberra: AIHW, 2010. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468376
2. Fong G, Hammond D, Laux F, Zanna M, Cummings K, Borland R, et al. The near-universal experience of regret among smokers in four countries: findings from the International Tobacco Control Policy Evaluation Survey. Nicotine & Tobacco Research 2004;6(suppl 3):S341–51. Available from: http://www.informaworld.com/smpp/content~content=a753998174~db=all~order=page
3. Borland R, Partos TR, Yong HH, Surname KM and Hyland A. How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control 4-Country cohort survey. Addiction 2012;107(3):673-82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21992709
4. Australian Bureau of Statistics and Australian Institute of Health and Welfare. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples, 2010 Canberra: 4704.0. 2010 Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4704.0
5. Ministerial Council on Drug Strategy. Australian National Tobacco Strategy 2004-2009. Canberra: Department of Health and Ageing, 2005. Available from: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-pub-tobacco-tobccstrat2-cnt.htm
6. Ministerial Council on Drug Strategy. Meeting the challenges of the next five years-3 Ideas and resources for improving services and treatment for smokers. National Tobacco Strategy, supporting documents. Canberra: Department of Health and Ageing, 2005. Available from: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-pub-tobacco-tobccstrat2-cnt.htm/
7. Raw M. Framework Convention on Tobacco Control (FCTC) Article 14 guidelines: a new era for tobacco dependence treatment. Addiction 2011;106(12):2055-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21827557
8. Conference of the Parties to the WHO Framework Convention on Tobacco Control. Guidelines for implementation of Article 14 (demand reduction measures concerning tobacco dependence and cessation). Decision FCTC/COP4(8), Geneva: World Health Organization, 2010. Available from: http://www.who.int/fctc/protocol/guidelines/adopted/article_14/en/index.html
9. The Ministerial Council on Drug Strategy. National Drug Strategy 2010-2015. 2011. Available from: http://www.health.gov.au/internet/drugstrategy/publishing.nsf/Content/nds2015
10. Preventative Health Taskforce. Australia: the healthiest country by 2020. National Preventative Health Strategy. Canberra: Commonwealth of Australia, 2009. Available from: http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/national-preventative-health-strategy-1lp
11. Tobacco Working Group. Technical report no. 2. Tobacco in Australia: making smoking history. Canberra: National Preventative Health Taskforce, 2008. Available from: http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/tech-tobacco
12. Commonwealth of Australia. Taking Preventative action: a response to 'Australia: the Healthiest Country by 2020. The report of the national Preventative Health Taskforce 2010. Available from: www.health.gov.au/internet/preventativehealth/publishing.../tpa.pdf
13. Commonwealth of Australia, the State of New South Wales, the State of Victoria, the state of Queensland, the state of Western Australia, the state of South Australia, et al. National Partnership Agreement on Preventive Health. Council of Australian Governments, 2009. Available from: http://www.federalfinancialrelations.gov.au/content/national_partnership_agreements/health/preventative_health/national_overview.pdf